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Special Report: Annotated Bibliography for
Managed Behavioral Health Care 1989-1999
Provider Issues
206. Armenti, N. P. (1991). The provider network in managed care.
The Behavior Therapist, 123-128.
This article describes the characteristics of providers who might be most successful in a
managed care system. These include having substance abuse training and experience; the
ability to provide emergency and crisis intervention; behavioral training; a demonstrated
ability to use community resources; and a community mental health or agency background.
The author describes some of the varying styles of managed care for providers and suggests
that providers also need to be selective when choosing a managed care arrangement to join.
Keyword: providers
207. Austad, C. S., & Berman, W. S. (1991). Managed health care and
the evolution of psychotherapy. In C. S. Austad & W. H. Berman (Eds.),
Psychotherapy in managed health care: The optimal use of time and
resources (1st ed., pp. 3-18). Washington, DC: American Psychological
Association.
This chapter, written by the book’s editors, describes how the changing health care system
has impacted the field of psychotherapy. They examine the evolution of short-term therapy,
and describe the commonalities in all of the therapies practiced in managed care settings.
Psychotherapy as it is practiced in the HMO setting is discussed, as are controversies in and
about managed health care.
Keywords: providers, psychotherapy
208. Austad, C. S., Sherman, W. O., Morgan, T., & Holstein, L. (1992).
The psychotherapist and the managed care setting. Professional
Psychology Research and Practice, 23, 329-332.
This study explores the practice patterns and attitudes of 43 mental health professionals working
in staff-model HMOs in the Northeast. Participants were asked to respond to semi-structured
and open-ended questions about their work setting, burnout, graduate training, and the evolution
of their practice style. Therapists were found to "happen" into the HMO setting and to possess
little information about HMOs prior to their employment. Participants reported that their work
involves a high level of direct client contact, that they use mostly brief therapy methods, and that
they use a variety of strategies to prevent burnout. The study also discusses the ways in which
psychologists differ from other mental health professionals in their practice styles.
Keywords: providers
209. Backlar, P. (1996). Managed mental health care: Conflicts of interest in
the provider/client relationship. Community Mental Health Journal, 32(2),
101-106.
This article is a theoretical analysis of the conflicts of interest confronting health care providers
with special attention paid to mental health providers and the implicit economic conflicts of
interest brought about by managed care. According to the author, there are three primary posi-tions
where conflicts of interest arise in health care: when providers promote their clients’
interests over all other interests; when providers promote the general social good by acting as
rational resource allocators; and when providers promote their own financial well-being at the
expense of all other interests. The author argues that conflicts of interest in managed mental
health care are distinct from those that arise in traditional health care services because the
mentally ill population oftentimes has a limited ability to care for itself or to make informed
choices. Therefore, the author sees a potential loss of confidentiality in patient care for people
with mentally illness, as well as a potential conflict between the provider’s personal financial
loyalties and the patient’s interests.
Keywords: ethics, providers
210. Baker, N. J., & Giese, A. A. (1992). Reorganization of a private
psychiatric unit to promote collaboration with managed care. Hospital
and Community Psychiatry, 43, 1126-1129.
Over the past five years, an increased number of managed care organizations in the Denver,
Colorado, area have challenged psychiatric hospitals to reduce costs and length of stay. This
article describes the experience of one private psychiatric hospital unit that reorganized a
locked unit into three progressively less restrictive ones through which patients could progress
at their own rate. In the first year after reorganization, length of stay and staffing costs were
significantly reduced. This article describes these and other impacts of this hospital-based
alternative model.
Keywords: models, providers
211. Barnes, P. D. (1991). Managed mental health care: A balancing act.
Administration and Policy in Mental Health, 19, 51-55.
Managed mental health care is characterized by tensions between countervailing interests,
goals, and approaches. In this opinion piece, the author identifies some of the areas in which
mental health professionals are working to strike a balance, and the implications of the choices
that they make. Managed care companies’ desire to use a selected panel of providers must be
balanced against consumer freedom of choice; quality control must be balanced against the
need to control costs; utilization review must serve providers, consumers, and payors alike; and
mental health goals must be balanced with health care goals. After describing these tensions,
the author outlines methods to reduce adversarial relationships, arguing that the behavior of
managed health care and practitioners will eventually become more similar and collaborative.
Keyword: providers
212. Bennett, M. J. (1992). The managed care setting as a framework for
clinical practice. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental
health care: Administrative and clinical issues (1st ed., pp. 203-217).
Washington, DC: American Psychiatric Press.
The author describes a treatment model for psychotherapy in a managed setting that was
developed with over 20 years of experience in an HMO environment. The treatment model,
referred to as focal psychotherapy, consists of five phases that can be characterized along six
axes. This treatment model is described, as are the implications of this model for assessment
and monitoring client progress. The author argues that this model is responsive to patient
needs as well as cost-effective. He asserts that although the focal psychotherapy originated in
a closed setting, the model is compatible with a wide variety of clinical settings with similar
missions.
Keywords: models, providers, psychotherapy
213. Berkman, A. S., Bassos, C. A., & Post, L. (1988). Managed mental
health care and independent practice: A challenge to psychology.
Psychotherapy, 25, 434-440.
This article addresses ways in which high quality of care can be delivered within a framework
that emphasizes cost-containment. The authors outline the key strategies of the Synton Group,
a mental health management firm. These strategies include diagnostic consultation; utilization
management committee; and use of patient satisfaction surveys. The article describes critical
issues that managed care systems should consider: using experienced providers; meeting both
clinical and financial goals; establishing effective mechanisms to ensure access to care; and
matching patients with providers and treatment. The authors also discuss the various arrange-ments
between managed care firms and providers, and their advantages and disadvantages.
Finally, the article reviews questions regarding what constitutes effective mental health treat-ment,
and the role of diagnosis in such treatment.
Keywords: managed behavioral health care organizations, providers
214. Berman, W. H., & Austad, C. S. (1991). Managed mental health care:
Current status and future directions. In C. S. Austad & W. H. Berman (Eds.),
Psychotherapy in managed health care: The optimal use of time and
resources (1st ed., pp. 264-278). Washington, DC: American Psychological
Association.
This chapter, written by the book’s editors, provides an overview of the book. The authors write
that the purpose of the book has been to "describe optimal mental health care as it is practiced
by clinicians in managed health care systems." The collection of chapters demonstrates the vari-ous
ways that psychotherapists have adjusted their practices to accommodate changes in financ-ing
and organization of the mental health care system. This chapter summarizes some of the
innovations in theory, assessment, and treatment and explores current developments in program
development, treatment of chronic patients, and training and staff development.
Keyword: providers
215. Bittker, T. E. (1992). The emergence of prepaid psychiatry.
In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care:
Administrative and clinical issues (1st ed., pp. 3-10). Washington, DC:
American Psychiatric Press.
This chapter briefly describes the emergence of prepaid psychiatry over the past 25 years,
from its beginnings in the HMO movement of the 1960’s to its recent forms of managed care.
The author argues that physician surpluses and escalating medical care costs have promoted
an alliance between government, corporate America, and health insurers that has led to an
industrialization of medicine. He describes the impact of this industrialization on mental
health professionals and discusses the ways in which changes in the financing and organiza-tion
of psychiatric services will continue to impact psychiatry in the next century.
Keywords: overviews, providers, trends
216. Carson, D. (1993). Managed care: A provider perspective.
New Directions for Mental Health Services, 59, 81-87.
This chapter uses the experience of a private psychiatric hospital to describe the impact
on both the hospital and its staff of moving towards a managed care model. As in other
psychiatric hospitals, managed care led to a shift in focus from inpatient to outpatient care.
In addition to the impact on locus of care, there was a concomitant impact on length of
treatment, type of treatment, and range of services offered to clients by the hospital.
Moreover, managed care had a profound impact on clinicians. A detailed case example
describes the initial problems experienced by the hospital and staff, changes in staff
attitudes, administrative issues, financial issues, and the vision for the future.
Keyword: providers
217. Dewan, M. (1999). Are psychiatrists cost-effective? An analysis of
integrated versus split treatment. American Journal of Psychiatry, 156,
324-326.
Recent models of health care have emphasized the need to treat the patient holistically, inte-grating
behavioral health services and physical health services under one managed care organi-zation.
Yet within the realm of mental health, many health maintenance organizations (HMOs)
favor split treatment between psychiatrists and psychotherapists over integrated care by a sin-gle
provider because they assume split treatment will be less costly. In this study using 1998 fee
schedules from seven large managed care organizations and Medicare, the author models clini-cal
scenarios of psychotherapy alone, medication alone, and the combined treatment provided
by a psychiatrist or split with a psychologist or social worker. From the results, short-term
psychotherapy alone by a social worker is the least expensive modality. For patients who require
more intensive treatment, integrated care is less expensive than split treatment for almost all
treatment length scenarios. The author argues for further research to differentiate patients who
will respond better to brief psychotherapy alone compared with combined treatment.
Keywords: costs, integration, models, providers, psychotherapy
218. Dial, T. H., Bergsten, C., Haviland, M. G., & Pincus, H. A. (1998).
Psychiatrist and nonphysician mental health provider staffing levels in
health maintenance organizations. American Journal of Psychiatry, 155,
405-408.
Based on research from the Group Health Association of America (now the American
Association of Health Plans) concerning clinical staffing patterns in a sample of staff and
group model health maintenance organizations (HMOs), this study examines the ratios of full-time
psychiatrists to members and nonphysician mental health professionals to psychiatrists.
From the results, the overall mean number of psychiatrists per 100,000 HMO members is 6.8,
and there are 4.5 nonphysician mental health professionals on average for every licensed psy-chiatrist
in the plan. Compared to previous estimates of the required psychiatrist-to-population
ratios in fee-for-service and managed care environments, the overall number of psychiatrists
per 100,000 members is less than half the requirement for a fee-for-service environment esti-mated
in 1980 and about 40-80 percent greater than that for a managed care environment
estimated by later studies. The authors argue for the need of adequate projections of the future
demand for psychiatrists and suggest potential mechanisms to aid in this analysis.
Keyword: HMOs, providers, staffing
219. Dörken, H. (1994). Managed care intervenes where state
regulation fails. In S. A. Shueman, W. G. Troy, & S. L. Mayhugh (Eds.),
Managed behavioral health care: An industry perspective (pp. 113-126).
Springfield, IL: Charles C. Thomas.
In this chapter the author argues that managed care has brought the issue of clinical standards,
quality of care, and accountability to the fore. He discusses the inadequacies of regulatory enti-ties
to ensure competency among mental health providers and to maintain reasonable practice
standards through peer review. He reviews licensing and other legislation in the state of
California to demonstrate the inability of such legislation to regulate professional behavior.
Keywords: California, legislation, providers
220. Dorwart, R. A. (1990). Managed mental health care: Myths and
realities in the 1990s. Hospital and Community Psychiatry, 41, 1087-1091.
As managed mental health care is becoming the norm for people who are insured, concerns
about the effects of managed care are increasingly being raised by both clients and providers.
These concerns have focused around whether managed care really reduces costs, whether it
adversely affects the quality of care, and the ways in which it affects access to care. The author
calls for more and better research to answer some of these questions and debunk some of the
myths about managed health care. This research would ideally lead to better communication
between mental health professionals and managed care organizations.
Keyword: providers
221. Feldman, J. L. (1992). The managed care setting and the
patient-therapist relationship. In J. Feldman & R. J. Fitzpatrick (Eds.),
Managed mental health care: Administrative and clinical issues
(1st ed., pp. 219-229). Washington, DC: American Psychiatric Press.
This chapter delineates five major aspects of managed care practice that influence the patient-therapist
relationship. These are payment, systems issues, regulatory issues, internal manage-ment
issues, and organizational values. The author discusses each of these issues in a managed
care setting. She argues that the overall values and philosophy of an organization will signifi-cantly
impact the therapeutic relationship. She presents a model of the therapeutic relationship
as a "family triad" of patient, therapist, and organization, and asserts that alliances between
any two of the parties will impact the quality of the relationship between the patient and the
clinician and inevitably affect the outcome of therapy.
Keywords: overviews, providers
222. Feldman, J. L., & Fitzpatrick, R. (Eds.), (1992). Managed mental health
care: Administrative and clinical issues (1st ed.). Washington, DC:
American Psychiatric Press.
This book includes articles about managed mental health care from administrative as well as
clinical points of view. The book is divided into three sections: administrative issues (covering
the historical, economic, and managerial approaches to managed care); clinical issues (often
using a case study approach to discuss treatment approaches developed by the authors); and a
special issues section. Two chapters in the clinical issues section focus specifically on managed
care services for drug and alcohol abuse. In the final section on "special topics" are articles
discussing new delivery system approaches, including one that describes a computer-assisted
therapy method for short-term therapy.
Keyword: providers
223. Fowls, D. J. (1994). From managed care to cooperative care.
Managed Care Quarterly, 2(2), 46-50.
The tensions between managed care companies and providers of care have led to what this
author calls "organizational schizophrenia." This article addresses some of the reasons for the
lack of communication and cooperation between many providers of mental health care and the
managed care companies they work for. Two case studies are presented in which providers and
managed care companies have moved beyond a conflictual relationship to form a collaborative
one. The author argues that this can only happen with leadership from both camps and a
shared vision of quality and cost-effective care that puts the consumer and provider first.
Keyword: providers
224. Goldstein, L. S. (1989). Genuine managed care in psychiatry.
General Hospital Psychiatry, 11, 271-277.
In this article, the author describes a genuine managed mental health care system and the role
of psychiatrists in such a system. Genuine managed care is defined as a practice pattern that
mental health practitioners can use to deliver quality care cost-effectively. Practice pattern is
a structure for care, and includes provision of multiple services by a multidisciplinary staff.
It is also a process characterized by collaboration, utilization review, and quality assurance.
The author concludes by presenting an evaluation study analyzing the use of such a practice
pattern by a group practice.
Keyword: providers
225. Goodman, M., Brown, J., & Deitz, P. (1992). Managing managed care:
A mental health practitioner’s survival guide. Washington, DC: American
Psychiatric Press.
This book is written specifically for mental health practitioners who may need help under-standing
their evolving role in a managed mental health care system. It is intended to guide
the clinician through the review processes inherent in managed care services and to help them
develop appropriate treatment plans. The authors use clinical vignettes to illustrate how to
write patient impairment profiles and outcome objectives. In lengthy appendices, they provide
specific psychotherapeutic interventions for many common mental disorders.
Keywords: providers, technical assistance
226. Gould, R. L. (1992). Adult development and brief computer-assisted
therapy in mental health and managed care. In J. Feldman & R. J.
Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical
issues (1st ed., pp. 347-358). Washington, DC: American Psychiatric Press.
This chapter presents a model of adult development based on Erickson’s theory that develop-ment,
developmental blocks, and repair of previous developmental blocks occur at all ages.
This paradigm of adult development lends itself well to short-term therapy, i.e., the goal being
to find and resolve the current developmental block that is interfering with healthy function-ing.
The author proposes the therapeutic learning program, which is a computer-assisted brief
therapy program written for patients to work through themselves. The program consists of 10
interactive, sequential computer sessions. The patient also works with a therapist at the end of
each session. This chapter describes each of the goals and objectives of the 10 steps, describes
the advantages of such a program, and reviews an outcome study of the first 2,000 patients
using this method.
Keywords: models, providers, psychotherapy
227. Hoyt, M. F., & Austad, C. S. (1992). Psychotherapy in a staff model
health maintenance organization: Providing and assuring quality care in
the future. Psychotherapy, 29, 119-129.
This article describes "good" therapy in an HMO setting. The essential characteristics of such
therapy include crisis intervention; clear definition of patient and therapist roles; flexible and
creative use of time; interdisciplinary collaboration; use of multiple treatment models; intermit-tent
rather than long-term care; and utilization review. The authors recommend the use of
groups and family systems approaches, as well as growth-oriented rather than cure-oriented
approaches. They also review research evidence demonstrating the effectiveness of short-term
therapy and outline strategies to ensure that quality of care and accountability are maintained.
Keywords: HMOs, providers, psychotherapy
228. Jellinek, M. S., & Nurcombe, B. (1993). Two wrongs don’t make a
right: Managed care, mental health, and the marketplace. Journal of the
American Medical Association, 270, 1737-1739.
In this commentary, the authors describe the evolution of the mental health delivery system
from primarily "unleashed market forces" to "unopposed incentives to cut services." The
authors argue that just as there were few countervailing forces against overutilization and
misuse of mental health services in the 1980’s, there is currently little to check systematic
profiteering from underutilization of services. They discuss the implications of the decreasing
professional autonomy for psychiatrists and suggest what individuals and organizations can
do to pursue specific political objectives. The article describes implications for primary care
clinicians and why managed care represents both a threat and an opportunity.
Keyword: providers
229. Lane, N. E. (1994). Managed care and providers: You’re in business!
In S. A. Shueman, W. G. Troy, & S. L. Mayhugh (Eds.), Managed behavioral
health care: An industry perspective (pp. 65-75). Springfield, IL: Charles C.
Thomas.
This chapter explores issues in managed behavioral health care from the perspective of the
providers. The author directs her discussion to the mental health provider who may be feeling
disillusioned with the changes in the field during the past decade. She describes concrete ways
that providers can cope with these changes, such as how to view behavioral health services as
a commodity to be bought, sold, marketed, and negotiated. Finally, she suggests ways that
providers can approach managed care organizations about participation in their programs,
and how to negotiate with these companies.
Keyword: providers
230. Olsen, D. P., Rickles, J., & Travlik, K. (1995). A treatment-team model of
managed mental health care. Psychiatric Services, 46(3), 252-256.
This article examines the treatment-team model of managed care for mental health patients.
This model includes an in-person assessment by a clinician who acts as the managed care
agent, immediate accessibility of this clinician, referral services with a broad range of intensity,
and participation of the managed care clinician on the treatment team. The advantages of
this approach include an increased ability to provide patients with individualized services,
and a more organized system of care management. Limitations of the model include difficulty
in decision-making due to the presence of team decisions, and the potential for overuse of
emergency care by primary care physicians.
Keywords: models, providers
231. Patterson, D. Y., & Sharfstein, S. S. (1992). The future of mental health
care. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care:
Administrative and clinical issues (1st ed., pp. 335-346). Washington, DC:
American Psychiatric Press.
In this chapter, the authors speculate on what the future of mental health care will hold as we
move towards the 21st century. They review some of the critical historical turning points in
mental health policy and briefly discuss current trends. These include the growing role of
employers, perceived inadequacy of HMOs, widespread concern with the rapid rise of mental
health and substance abuse costs, and concurrent decline in Federal and State direct oversight
for public mental health care. They speculate that managed care will continue to grow in
importance, that there will be a clearer definition of private versus public responsibility for
health care, a clearer delineation of responsibilities between medical and nonmedical mental
health care professionals, growing involvement of employers in health care, and increasing
number of training programs to prepare clinicians for the 21st century.
Keywords: providers, trends
232. Resnick, R. J., Bottinelli, R. W., Puder-York, M., Harris, B., & O’Keefe,
B. E. (1994). Basic issues in managed mental health services. In R. L.
Lowman & R. J. Resnick (Eds.), The mental health professional’s guide to
managed care (pp. 41-62). Washington, DC: American Psychological
Association.
The chapter compares and contrasts the four most prevalent managed care systems: health
maintenance organizations, preferred provider organizations, employee assistance programs,
and competitive medical plans. The authors delineate the ways in which psychologists par-ticipate
in these systems—as owners, shareholders, independent providers, and employees.
Finally, the article examines the various professional relationship and practice issues that affect
providers who work in managed care settings. The authors conclude that mental health profes-sionals
in today’s practice environment need to be aware of the clinical and financial implica-tions
of managed care systems so that they participate effectively and influence their design.
Keywords: overviews, providers
233. Richardson, L. M., & Austad, C. S. (1991). Realities of mental health
practice in managed-care settings. Professional Psychology Research and
Practice, 22, 52-59.
This article describes aspects of the managed care system that are of concern to psychologists.
Topics discussed include mental health benefits under HMOs, the advantages and disadvan-tages
of employment as staff or contractors, financial considerations in providing services in
fee-for-service arenas, prospective payment and capitation plans, and potential barriers to
treatment. The authors also review practice issues. Psychologists working in HMOs continue
to prefer long-term psychodynamic approaches; however, efforts are underway to help these
practitioners develop skills in providing short-term therapy. The authors argue that psycholo-gists
in HMOs must address challenges such as reducing inpatient use, providing care for
chronically ill and noncompliant clients, and interacting effectively in an interdisciplinary
team. The pros and cons of providing service in a managed care system are outlined, as well
as criteria clinicians can use in working in such systems.
Keywords: overviews, providers
234. Richardson, L. M., & Austad, C. S. (1994). Realities of mental health
practice in managed-care settings. In R. L. Lowman & R. J. Resnick (Eds.),
The mental health professional’s guide to managed care (pp. 151-168).
Washington, DC: American Psychological Association.
See Richardson and Austad, 1991 (reference number 233) for annotation.
235. Root, L. S. (1991). Cost controls on mental health services: Context
and the role of the professional. Employee Assistance Quarterly, 7(2), 1-13.
Cost control is a key concern for employers; employee benefits represent 37.6 percent of U.S.
payroll costs. To address rising costs, employers offer health insurance through HMOs and
preferred provider organizations that is less expensive than fee-for-service plans. The author
describes three cost-containment strategies: exclusions and limits on coverage, managed care
carve-outs, and employee assistance programs as case managers, and explains how these
strategies are aimed at controlling behavior, use, and price. The author examines the context
of cost-control efforts in both mental health and substance abuse services. He argues that
mental health practitioners must be proactive and take initiative in creating an approach that
manages the care of clients, not simply limits the cost of the care.
Keywords: costs, providers
236. Sabin, J. E. (1991). Clinical skills for the 1990s: Six lessons from HMO
practice. Hospital and Community Psychiatry, 42, 605-608.
HMO clinical practice currently embodies many of the features that are being required of
managed mental health care providers. These include attention to cost containment, identifi-cation
of outcomes, practice audits and treatment guidelines. This author argues that identify-ing
the skills required for clinical effectiveness and professional satisfaction in the HMO can be extremely valuable for all clinicians working in a managed care environment. He identifies
six crucial skills that can help clinicians become more effective, and uses brief case examples
to illustrate how these skills may be useful in managed-care settings.
Keywords: HMOs, providers
237. Sabin, J. E., & Borus, J. F. (1992). Mental health teaching and research
in managed care. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental
health care: Administrative and clinical issues (1st ed., pp. 185-199).
Washington, DC: American Psychiatric Press.
In this chapter, the authors argue that the accelerating shift from fee-for-service to managed
care has created a need for a new set of training skills for clinicians to practice effectively.
This chapter delineates six new skills that managed care clinicians should possess. Several
examples of teaching programs designed to train mental health practitioners in skills appro-priate
for practicing in a managed care environment are presented. In a separate section, the
benefits and problems of conducting research in HMOs are discussed. The authors conclude
that both academic medical centers and HMOs will gain substantially by fostering meaningful
collaboration in training and research.
Keywords: providers, training
238. Sargent, S. C. (1992). Contracting and managed care payment options.
In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care:
Administrative and clinical issues (1st ed., pp. 53-67). Washington, DC:
American Psychiatric Press.
The author of this chapter argues that mental health providers in the 1990’s must be able to
design payment options that will work for them rather than respond to potentially inappro-priate
managed care offers. This chapter offers a template for mental health providers to use
when approaching and evaluating managed care opportunities. Six steps for managed care
contracting are discussed in detail: preparation, proposal, negotiation, contract, implementa-tion,
and evaluation/renegotiation. The author recommends that a provider have a template
such as this one to help assess whether any given managed care plan will meet the needs of
patients and their families.
Keywords: contracting, providers, technical assistance
239. Scheffler, R., & Ivey, S. L. (1998). Mental health staffing in managed
care organizations: A case study. Psychiatric Services, 49, 1303-1308.
Temporal changes in staffing numbers and ratios within health maintenance organizations
(HMOs) offer us a valuable tool for estimating the future composition of the health care work-force
as the trend toward managed care organizations continues. This article examines such
staffing configurations of mental health providers through case studies of two staff-model
HMOs. In an effort to address the move of many HMOs to contracting out mental health
services to specialized behavioral health organizations, the authors compare staffing ratios of
these HMOs with a 1-year average from a managed behavioral health carve-out organization in the same State. Results indicate a decline in total number of patient care physicians regard-less
of enrollment changes, similar ratios of general psychiatrists per 100,000 members
between the two HMOs that were about half the State’s average, and a higher percentage of
doctoral-level psychologists in the carve-out plan. The results highlight a need for future
research focused on outcome measurement, the possibility of improvements in service delivery
and quality through collaboration among provider types, and the effects of substituting non-specialist
physicians for behavioral health services.
Keywords: carve-outs, HMOs, managed behavioral health care organizations, providers,
staffing
240. Schreter, R. K. (1993). Ten trends in managed care and their impact
on the biopsychosocial model. Hospital and Community Psychiatry, 44,
325-327.
In this article, the author expresses concerns about the impact of managed care on the bio-psychosocial
model of diagnosis and treatment. He identifies 10 trends in managed care
and examines their impact on clinicians and their clients. He argues that managed care in its
present form is being transformed as mental health services are increasingly being carved out,
and provider networks are becoming the norm.
Keywords: providers, trends
241. Schreter, R. K., Sharfstein, S. S., & Schreter, C. A. (Eds.). (1994).
Allies and adversaries: The impact of managed care on mental health
services (1st ed.). Washington, DC: American Psychiatric Press.
This edited volume is a collection of essays written by clinicians and mental health executives.
The book revolves around paired essays (one representing the managed care view, the other
the clinical view). In a section on clinical services, inpatient services, intermediate level of
care, outpatient care, child and adolescent services, and drugs and alcohol are addressed. The
same format is used to show the two perspectives regarding the role of providers, including
the psychiatrist, psychologist, and social worker. Ethical issues under managed care, quality-of-
care guidelines, and practice guidelines are also addressed. Essayists were asked to respond
to two questions: What do you believe are the major problems with managed mental health
care? What would you do to improve the situation? Many of the chapters are written in an
informal, personal style with liberal use of anecdotes and case studies. The editors wrote the
final chapter, entitled "How Adversaries Can Become Allies," in which they outline the areas
of both conflict and agreement between managed care executives and clinicians and reiterate
the need for dialogue between the two groups.
Keyword: providers
242. Schuster, J. (1991). Ensuring highest-quality care for the cost: Coping
strategies for mental health providers. Hospital and Community Psychiatry,
42, 774-776.
Frustrated with mixed reviews regarding the ability of methods such as utilization review,
diagnosis-related groups (DRGs), and HMOs to control health care costs, the Federal
Government is now exploring other avenues to achieve cost control. These include increased
attention to outcome studies, renewed interest in a national health care system, and the enact-ment
of the Medicare Volume Performance Standard. Psychiatry has followed a different path
with regard to cost control; for example, most psychiatric services have not been subject to
DRG limitations. This author describes current cost-containment methods in mental health
care and concludes that mental health providers be proactive in exploring cost-containment
methods that provide the highest quality for the cost.
Keywords: costs, providers
243. Sederer, L. I., & St. Clair, R. L. (1989). Managed health care and the
Massachusetts experience. American Journal of Psychiatry, 146,
1142-1148.
Managed behavioral health care represents both danger and opportunity for psychiatry. The
authors describe some of the reasons for the rapid growth of managed care and the clinical,
economic, ethical, and practical implications. They then discuss the ways in which psychia-trists
have organized to counterbalance the trend. The authors describe the efforts of the Task
Force on Managed Care of the Massachusetts Psychiatric Society to ensure that psychiatrists
continue to play a major role in determining the destiny of psychiatric care. The task force
chose to focus on three areas: developing criteria for minimal standards of care; certification
and monitoring of utilization review organizations; and maintaining a second opinion service
as a back-up for when a psychiatrist or patient disagrees with a managed care organization.
Keywords: providers, standards of care, utilization management
244. Sederer, L. I. (1994). Managed mental health care and professional
compensation. Behavioral Sciences and the Law, 12, 367-378.
In this article, the author examines physicians’ organizational relationship to new managed
systems of care as well as physician compensation within these systems. The paper presents
three models of professional compensation: profit maximization, target income, and patient
agency. The author then describes five different types of physician organizations, entities
integrating physicians with health care systems. From these foundations, the author discusses
the impact of managed mental health care on physician compensation and incentives, con-cluding
that fully integrated, physician-hospital organizations with target income compensa-tion
arrangements are the most successful for both physicians and organized systems of care.
The paper includes a discussion of the dilemmas and challenges in bringing together managed
care, organized networks of care, and professional compensation.
Keywords: economics, models, providers
245. Snibbe, J. R., Radcliffe, T., Weisberger, C., Richards, M, & Kelly, J.
(1989). Burnout among primary care physicians and mental health
professionals in a managed health care setting. Psychological Reports, 65,
775-780.
The authors administered the Maslach Burnout Inventory to primary care physicians and psy-chiatric
staff (psychiatrists, psychologists and social workers) of a large health maintenance
organization (HMO). They found that for all providers except psychologists, their HMO
sample scored significantly higher on all subscales than the Maslach normative population of
physicians and mental health professionals. Several interprofessional differences also emerged.
For example, internists scored significantly lower on emotional exhaustion than did psychia-trists;
however, psychiatrists scored higher on depersonalization than either family practition-ers
or internists. The authors discuss implications of these findings for HMOs that include job
rotation, mentoring systems, and workshops to help health care professionals recognize and
cope with burnout.
Keywords: HMOs, providers
246. Sturm, R., Meredith, L. S., & Wells, K. B. (1996). Provider choice and
continuity for the treatment of depression. Medical Care, 34(7), 723-734.
This article examines the effects that the changing payment system in mental health care has
had on characteristics of the patient-provider relationship such as a choice of specialist versus
generalist, and the duration of the relationship. The authors compare provider selection among
depressed patients in prepaid and traditional fee-for-service (FFS) plans. Data from the Medical
Outcomes Study are analyzed among three competing systems of care in urban areas across the
country. The results of the patient survey administered by the authors finds that FFS patients
were more likely than those in prepaid health plans to consider a psychiatrist to be their main
source of care. FFS individuals were also found to have a higher probability of provider conti-nuity
over time than those in prepaid health plans. This study may be useful in future policy
analysis on issues of patient-provider relationships as well as the quality of care being offered
in the managed behavioral health care market.
Keywords: depression, evaluation, providers
247. Thompson, J. W., Smith, J., Burns, B. J., & Berg, R. (1991). How
mental health providers see managed care. Journal of Mental Health
Administration, 18, 284-291.
This paper reports the findings from a 1989 study using focus groups to explore mental health
practitioners’ attitudes regarding managed care. The 23 participants (psychologists and psychi-atrists)
were ether contractors with managed care firms or on an "approved" list of providers.
Although there were differences of opinion on a number of points, the general consensus of
the groups was that managed care has adversely affected quality of care as well as their own
practice. Participants believed that limits on the number of sessions and inpatient stays inter-fered
with effective treatment. They identified barriers to engaging clients such as inappropri-ate
intake assessments by untrained case managers and the subjective use of "standardized" criteria. The participants called for peer review, greater collaboration between providers
and managed care firms, more stability in benefits and standards, and more autonomy in
decision-making.
Keyword: providers
248. Van Gelder, D. W. (1992). Surviving in an era of managed care:
Lessons from Colorado. Hospital and Community Psychiatry, 43,
1145-1147.
This paper discusses how managed care has affected nonprofit psychiatric facilities in
Colorado, where more than half of the State’s population is covered by managed care plans.
The author describes the strategies one facility has used to function effectively in an era of
cost containment. Because of a decrease in length of stay, the facility needs more patients to
maintain a full census. To achieve this, the facility has trained staff in brief treatment and
implemented a marketing campaign to generate referrals. The author suggests a number of
approaches to prevent declines in employee morale should layoffs become necessary. These
include making the facility mission clear to employees and giving them a say in decisions
about cutbacks.
Keyword: providers
249. Wagman, J. B., & Schiff, J. (1990). Managed mental health care for
employees: Roles for social workers. Occupational Social Work Today,
53-65.
Case management is a major strategy for controlling skyrocketing mental health costs. The
authors identify the causes of the problem of high costs, how case management is being used
to address this problem, and the role of social workers in case management and employee
assistance programs. Social workers possess skills that are useful in assessment and referral,
as well as in review and monitoring of treatment. Managed mental health care has provided
many opportunities for clinicians who are competent in both direct practice and administrative
skills. The authors argue that as the field of managed mental health care grows, social work
education will need to address the emerging roles that it presents for social workers.
Keywords: case management, providers
250. Whittington, H. G. (1992). Managed mental health: Clinical myths
and imperatives. In S. Feldman (Ed.), Managed mental health services
(1st ed., pp. 223-244). Springfield, IL: Charles C. Thomas.
This chapter argues that the clinical, social, and economic imperatives in favor of a managed
mental health approach are compelling. The author identifies and refutes a number of myths
about managed mental health care. These include beliefs such as that controlling physician
behavior is amenable to simple economic incentives; that mental health care is unmanageable;
that adverse selection will occur if good mental health benefits are offered; that patients as
a rule overutilize psychotherapy, and that managed care results in poorer service outcomes.
The author argues that the skepticism with which managed mental health and substance
abuse services are viewed by the general public and payors is largely due to ignorance about
the clinical and economic realities of such services; and that managed mental health repre-sents
an opportunity to improve both clinical outcomes and economic efficiency.
Keywords: economics, providers
251. Zakheim, M. H., Leifer, J. C., & Schwartz, R. A. (1998). A guide for
providers of mental health and addictive disorder services in managed
care contracting: Vol. 9. Managed care technical assistance series.
Rockville, MD: Substance Abuse and Mental Health Services
Administration.
As more and more health care providers are contracting with managed care organizations,
it has become increasingly important for providers to understand the structure and organiza-tion
of these contracts before they begin to negotiate. The purpose of this guide is to assist
providers of publicly funded substance abuse and mental health services as they enter into
contracts with managed care organizations. In particular, the discussion centers around the
wording of these contracts, with a focus on identifying commonly found weaknesses in the
provisions and recommending alternatives. The guide is composed of five sections: Funda-mentals
of Managed Care Contracting, Scope of Services, Financial Issues, Eligibility and
Enrollment, and Dispute Resolution and Conditions of Termination. Each chapter presents
a discussion of a specific type of contract provision as exemplified by relevant excerpts from
actual contracts followed by critiques and recommendations.
Keywords: contracting, providers, public sector, substance abuse, technical assistance
252. Zimet, C. N. (1989). The mental health care revolution:
Will psychology survive? American Psychologist, 44, 703-708.
The author argues that psychologists should help shape the managed care system. The key
tasks for psychologists are to provide high-quality care and to assert their role in providing
that care. The article provides an overview of managed care as a cost-containment approach.
Although psychiatric hospitals have been exempted from cost containment, it is only a matter
of time before these facilities are reimbursed prospectively and treatments are paid at a fixed
rate. Reimbursement limits will have important implications for psychologists. The article also
describes the ways in which psychologists can play a role in assuring quality assurance, developing
reimbursement guidelines, and in advocating for the use of mental health services as a
way of reducing medical costs.
Keyword: providers
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